Denika Y. Douglas, Ph.D. 
Licensed Psychologist (Lic.# 35076)
Licensed Specialist in School Psychology (Lic.# 34421)

4801 Woodway Dr., Suite 300E														    				 (713) 574-8502
Houston, Texas 77056												    			   drdouglas@douglassolutions.com

_______________________________________________________________________________________________

Young Adult Information Form 

Note: Unless there is a serious risk of injury to you or someone else, the information on this form is confidential. It will not be discussed with your parents without your consent. 

Your name: ____________________________________ Nickname? ____________________________________
Today’s date: ______________	Your age: _________ Your phone #: _____________________________
Your address: _________________________________________________________________________________  

Health 
How tall are you? ___	____   What do you consider your ideal weight? _____ Has your weight changed more than 10 pounds in the last year?  ❑ No	❑ Yes  How much? _____  Why? ___________________________
What physical or medical problems do you have now, or have you had in the past?  ____________________
_______________________________________________________________________________________

Family

Birth parents’ names: _____________________________________ and ______________________________________
Address: _________________________________________________________________ Phone # ________________
Present parents’/guardians’ names:  _______________________________ and _______________________________
Address: _________________________________________________________________ Phone # _______________

How would you describe your parents’ relationship? _________________________________________________

What kinds of problems are you having with: 
	Parents/stepparents/guardians? 

	Parents’ live-in friends or boyfriends/girlfriends? 

	Brothers or sisters (or stepbrothers or stepsisters)? 

School 

Which school do you go to? __________________________________________ Grade level/year: ________

How are your grades? _____________________________________________________________________

Problems in school? ______________________________________________________________________

________________________________________________________________________________________________

Work 

Do you work?  ❑ No   If so, How many hours a week?  ______ What do you do? ____________________

Problems there? _________________________________________________________________________

Friends 
Who are your close friends (names and ages)? 

Do you have a serious one-on-one relationship now?  ❑ No   ❑  Yes

Do you party? _______ If so, when and where? _________________________________________________

Previous counseling 

1. With whom? _______________________________________________  When? ____________________

For what? ______________________________________________________________________________

With what results? ________________________________________________________________________

2.  With whom? ____________________________________________ When?   _____________________

For what? ______________________________________________________________________________

With what results? _______________________________________________________________________

Concerns 

Would you like information or answers on:  ❑ Sex (of any kind)  ❑ Birth control   ❑  Alcohol  ❑  Drugs
❑ Relationships  ❑ Other concerns: ___________________________________________________________________

How important is religion to you and/or your family? __________ If so, in what ways? ___________________________

________________________________________________________________________________________________

What worries or upsets you? ________________________________________________________________________

_______________________________________________________________________________________________

What makes you happy? 

Why do you think you are here? Please tell me in your own words. 

What would you like to see happen or change because of this counseling? 

What would you like me to let your parents know? 

What else is important for me to know? 

What would you like me to ask you about? 

Signed:  _________________________________________  

Date:_________________________________________

This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. 

(cont.)
FORM 34. Information form for young adults (p. 1 of 3). Adapted from a form devised by Nora Fleming Young, PhD, of Mayer AZ, and used by permission of Dr. Young.—From The Paper Office. Copyright 2008 by Edward L. Zuckerman. Permis­sion to photocopy this handout is granted to purchasers of this book for personal use only (see copyright page for details).